The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program

Altmetric Versus Bibliometric Perspective Regarding Publication Impact and Force

BACKGROUND

Bibliometric and Altmetric analyses highlight key publications, which have been considered to be the most influential in their field. The hypothesis was that highly cited articles would correlate positively with levels of evidence and Altmetric scores (AS) and rank.

METHODS

Surgery as a search term was entered into Thomson Reuter's Web of Science database to identify all English-language full articles. The 100 most cited articles were analysed by topic, journal, author, year, institution, and AS.

RESULTS

By bibliometric criteria, eligible articles numbered 286,122 and the median (range) citation number was 574 (446-5746). The most cited article (Dindo et al.) classified surgical complications by severity score (5746 citations). Annals of Surgery published most articles and received most citations (26,457). The country and year with most publications were the USA (n = 50) and 1999 (n = 11). By Altmetric criteria, the article with the highest AS was by Bigelow et al. (AS = 53, hypothermia's role in cardiac surgery); Annals of Surgery published most articles, and the country and year with most publications were USA (n = 4) and 2007 (n = 3). Level-1-evidence articles numbered 13, but no correlation was found between evidence level and citation number (SCC 0.094, p = 0.352) or AS (SCC = 0.149, p = 0.244). Median AS was 0 (0-53), and in articles published after the year 2000, AS was associated with citation number (r = 0.461, p = 0.001) and citation rate index (r = 0.455, p = 0.002). AS was not associated with journal impact factor (r = 0.160, p = 0.118).

CONCLUSION

Bibliometric and Altmetric analyses provide important but different perspectives regarding article impact, which are unrelated to evidence level.

Resident-Specific Morbidity Reduced Following ACS NSQIP Data-Driven Quality Program

BACKGROUND

The Accreditation Council for Graduate Medical Education Milestone Project for general surgery provided a more robust method for developing and tracking residents' competence. This framework enhanced systematic and progressive development of residents' competencies in surgical quality improvement.

STUDY DESIGN

A 22-month interactive, educational program based on resident-specific surgical outcomes data culminated in a quality improvement project for postgraduate year 4 surgery residents. Self- assessment, quality knowledge test, and resident-specific American College of Surgeons National Surgical Quality Improvement Program Quality In-Training Initiative morbidity were compared before and after the intervention.

RESULTS

Quality in-training initiative morbidity decreased from 25% (82/325) to 18% (93/517), p = 0.015 despite residents performing more complex cases. All participants achieved level 4 competency (4/4) within the general surgery milestones improvement of care, practice-based learning and improvement competency. Institutional American College of Surgeons National Surgical Quality Improvement Program general surgery morbidity improved from the ninth to the sixth decile. Quality assessment and improvement self-assessment postintervention scores (M = 23.80, SD = 4.97) were not significantly higher than preintervention scores (M = 19.20, SD = 5.26), p = 0.061. Quality Improvement Knowledge Application Tool postintervention test scores (M = 17.4, SD = 4.88), were not significantly higher than pretest scores (M = 13.2, SD = 1.92), p = 0.12.

CONCLUSION

Sharing validated resident-specific clinical data with participants was associated with improved surgical outcomes. Participating fourth year surgical residents achieved the highest score, a level 4, in the practice based learning and improvement competency of the improvement of care practice domain and observed significantly reduced surgical morbidity for cases in which they participated.

Uterine weight and complications after abdominal, laparoscopic, and vaginal hysterectomy

BACKGROUND

Although uterine size has been a previously cited barrier to minimally invasive hysterectomy, experienced gynecologic surgeons have been able to demonstrate that laparoscopic and vaginal hysterectomy is feasible with increasingly large uteri. By demonstrating that minimally invasive hysterectomy continues to have superior outcomes even with increased uterine weights, opportunity exists to meaningfully decrease morbidity, mortality, and cost associated with abdominal hysterectomy.

OBJECTIVE

We sought to determine if there is an association between uterine weight and posthysterectomy complications and if differences in that association exist across vaginal, laparoscopic, and abdominal approaches.

STUDY DESIGN

We conducted a cohort study of prospectively collected quality improvement data from the American College of Surgeons National Surgical Quality Improvement Program database, composed of patient information and 30-day postoperative outcomes from >500 hospitals across the United States and targeted data files, which includes additional data on procedure-specific risk factors and outcomes in >100 of those participating hospitals. We analyzed patients undergoing hysterectomy for benign conditions from 2014 through 2015, identified by Current Procedural Terminology code. We excluded patients who had cancer, surgery by a nongynecology specialty, or missing uterine weight. Patients were compared with respect to 30-day postoperative complications and uterine weight, stratified by surgical approach. Bivariable tests and multivariable logistic regression were used for analysis.

RESULTS

In all, 27,167 patients were analyzed. After adjusting for potential confounders, including medical and surgical variables, women with 500-g uteri were >30% more likely to have complications compared to women with uteri ≤100 g (adjusted odds ratio, 1.34; 95% confidence interval, 1.17-1.54; P < .0001), women with 750-g uteri were nearly 60% as likely (adjusted odds ratio, 1.58; 95% confidence interval, 1.37-1.82; P < .0001), and women with uteri ≥1000 g were >80% more likely (adjusted odds ratio, 1.85; 95% confidence interval, 1.55-2.21; P < .0001). The incidence of 30-day postsurgical complications was nearly double in the abdominal hysterectomy group (15%) compared to the laparoscopic group (8%). Additionally, for each stratum of uterine weight, abdominal hysterectomy had significantly higher odds of any complication compared to laparoscopic hysterectomy, even after adjusting for potential demographic, medical, and surgical confounders. For uteri <250 g, abdominal hysterectomy had twice the odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.80-2.33), and among women with uteri between 250-500 g, abdominal hysterectomy was associated with an almost 80% increase in odds of any complication (adjusted odds ratio, 1.76; 95% confidence interval, 1.41-2.19). Even among women with uteri >500 g, abdominal hysterectomy was still associated with a >30% increased odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 1.35; 95% confidence interval, 1.07-1.71).

CONCLUSION

We found that while uterine weight was an independent risk factor for posthysterectomy complications, abdominal hysterectomy had higher odds of any complication, compared to laparoscopic hysterectomy, even for markedly enlarged uteri. Our study suggests that uterine weight alone is not an appropriate indication for abdominal hysterectomy. We also identified that it is safe to perform larger hysterectomies laparoscopically. Patients may benefit from referral to experienced surgeons who are able to offer laparoscopic hysterectomy even for markedly enlarged uteri.

Pediatric Appendicitis Severity in KwaZulu-Natal, South Africa: A Retrospective Cohort Analysis

BACKGROUND

Acute appendicitis is a common pediatric surgical emergency; however, there are few grading systems to assign disease severity. The American Association for the Surgery of Trauma (AAST) recently developed a grading system for a variety of emergency surgical conditions, including appendicitis. The severity of acute appendicitis in younger patients in KwaZulu-Natal (South Africa) is unknown. We aimed to describe the disease severity in this patient population using the AAST grading system hypothesizing that the AAST grade would correlate with morbidity, management type, and duration of stay.

MATERIALS

Single institutional review of patients <18 years old with a final diagnosis of acute appendicitis during 2010-2016 in KwaZulu-Natal, South Africa, was performed. Demographics, physiologic and symptom data, procedural details, postoperative complications, and Clavien-Dindo classification were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and nominal logistic regression analyses were performed to compare AAST grade and outcomes.

RESULTS

A total of 401 patients were identified with median [IQR] age of 11 [5-13], 65% male. Appendectomy was performed in all patients; 2.4% laparoscopic, 37.6% limited incision, and 60% midline laparotomy. Complications occurred in 41.6%, most commonly unplanned relaparotomy (22.4%), surgical site infection (8.9%), pneumonia (7.2%), and acute renal failure (2.9%). Complication rate and median length of stay increased with greater AAST grade (all p < 0.001). AAST grade was independently associated with increased risk of complications.

CONCLUSION

Pediatric appendicitis is a morbid disease in a developing middle-income country. The AAST grading system is generalizable and accurately corresponds with management strategies as well as key clinical outcomes.

LEVEL OF EVIDENCE

Retrospective study, Level IV.

STUDY TYPE

Retrospective single institutional study.

The Safety and Feasibility of Gynecologic Cancer Surgery Combined With Surgery for Pelvic Floor Dysfunction

OBJECTIVES

Women with gynecologic cancer may also present with pelvic floor dysfunction that can have a significant effect on quality of life. Combined surgical intervention for both malignancy and pelvic floor dysfunction may improve quality of life with minimal additional risk. We sought to determine the safety, feasibility, and frequency of combined gynecologic cancer surgery and surgery for pelvic floor dysfunction.

METHODS

This is a retrospective cohort study that utilized the National Surgical Quality Improvement Program database provided through the American College of Surgeons. The National Surgical Quality Improvement Program database was queried for patients with a final diagnosis of gynecologic malignancy from 2011 to 2015. Common Procedural Terminology codes for gynecologic oncology procedures and pelvic floor dysfunction surgery were used to identify the study population. Baseline demographics and postoperative complications were abstracted from the database for these patients and compared for patients with combined surgeries versus gynecologic cancer surgeries alone.

RESULTS

One hundred twenty-nine women underwent combined procedures compared with 25,838 women undergoing gynecologic cancer surgery alone. Patients who underwent combined procedures were older, had lower body mass index, had higher preoperative albumin and hematocrit, and lower morbidity estimates (P < 0.05). Mean operative time was longer (226.4 vs 174.4 minutes, P < 0.01). There were no statistically significant differences in race, ethnicity, or medical comorbidities. There were no statistically significant differences in postoperative complications or readmissions between the 2 groups (P > 0.1).

CONCLUSIONS

Combined gynecologic cancer and pelvic floor dysfunction procedures are feasible and can safely be performed without differences in postoperative complications in appropriately selected patients.

International benchmarking in oesophageal and gastric cancer surgery

Background

Benchmarking on an international level might lead to improved outcomes at a national level. The aim of this study was to compare treatment and surgical outcome data from the Swedish National Register for Oesophageal and Gastric Cancer (NREV) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA).

Methods

All patients with primary oesophageal or gastric cancer who underwent a resection and were registered in NREV or DUCA between 2012 and 2014 were included. Differences in 30‐day mortality were analysed using case mix‐adjusted multivariable logistic regression.

Results

In total, 4439 patients underwent oesophagectomy (2509 patients) or gastrectomy (1930 patients). Estimated resection rates were comparable. Swedish patients were older but had less advanced disease and less co‐morbidity than Dutch patients. Neoadjuvant treatment rates were lower in Sweden than in the Netherlands, both for patients who underwent oesophagectomy (68·6 versus 90·0 per cent respectively; P < 0·001) and for those having gastrectomy (38·3 versus 56·6 per cent; P < 0·001). In Sweden, transthoracic oesophagectomy was performed in 94·7 per cent of patients, whereas in the Netherlands, a transhiatal approach was undertaken in 35·8 per cent. Higher annual procedural volumes per hospital were observed in the Netherlands. Adjusted 30‐day and/or in‐hospital mortality after gastrectomy was statistically significantly lower in Sweden than in the Netherlands (odds ratio 0·53, 95 per cent c.i. 0·29 to 0·95).

Conclusion

For oesophageal and gastric cancer, there are differences in patient, tumour and treatment characteristics between Sweden and the Netherlands. Postoperative mortality in patients with gastric cancer was lower in Sweden.

The impact of timing of antibiotics on in-hospital outcomes after major emergency abdominal surgery

BACKGROUND

Patients undergoing major open emergency abdominal surgery experience high morbidity and mortality rates and often have sepsis at admission. The purpose of this study was to evaluate the association between antibiotic timing and in-hospital outcomes such as complications, need for reoperation, length of stay, and 30-day mortality.

METHODS

This retrospective observational cohort study was conducted between January 2010 and December 2015 including patients that were triaged through the emergency department for subsequent major open abdominal surgery. All relevant perioperative data were extracted from medical records. The outcomes of interest were development of in-hospital postoperative complications, reoperations, length of stay, and 30-day mortality, all in association with antibiotic timing, categorized according to 0-6, 6-12, or > 12 h from triage. Multivariate logistic regression was performed to evaluate adjusted outcomes associated with antibiotic timing.

RESULTS

A total of 408 patients were included, of whom 107 (26.2%) underwent at least one reoperation and 55.4% had at least one postoperative complication. These complications consisted of 26% surgical complications and 74% medical complications. Of the surgical complications, 73% were Clavien-Dindo ≥ 3. The median length of stay was 9 days and the overall 30-day mortality was 17.9%. The data showed that the development of complications, need for reoperation, 30-day mortality, and the length of stay were significantly correlated to delayed antibiotic administration of more than 12 h from admission.

CONCLUSIONS

Antibiotic administration more than 12 h from triage was associated with a significantly increased risk of postoperative complications, need for reoperation, 30-day mortality, and a prolonged length of stay, when compared to patients that received antibiotic treatment 0-6 h and 6-12 h after triage. Our data suggest that prophylactic antibiotics should be administered to all patients undergoing major open emergency abdominal surgery; however, the dose and duration cannot be concluded on the basis of our data and should be further examined.

Publicly Available Databases in Otolaryngology Quality Improvement

The historical context for quality improvement is provided. Important differences are described between the two overarching types of databases: clinical registries and administrative databases. The pros and cons of each are provided as are examples of their utilization in otolaryngology-head and neck surgery.

Walk a Mile in the Leadership's Shoes: Why Focus on Quality Improvement?

Quality Improvement (QI) throughout health care in the United States continues to be of growing importance to both patients and providers. Leaders in health care including physicians, nurses, hospital administrators, and payors are all responsible for ensuring the continuation and growth of QI initiatives. This article will discuss various ways that healthcare leaders, with specific regard to orthopedic surgery, have utilized QI measures to provide better, more efficient, care to patients.

Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission

Importance

Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission.

Objective

To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes.

Design, Setting, and Participants

A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded.

Exposures

Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL).

Main Outcomes and Measures

Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome.

Results

Of 346 676 surgeries, 153 767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P < .001) and readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, P < .001). After adjustment, preoperative proteinuria was associated with postoperative AKI in a dose-dependent relationship (trace: odds ratio [OR], 1.2; 95% CI, 1.1-1.3, to 3+: OR, 2.0; 95% CI, 1.8-2.2) and 30-day unplanned readmission (trace: OR, 1.0; 95% CI, 1.0-1.1, to 3+: OR, 1.3; 95% CI, 1.1-1.4). Preoperative proteinuria was associated with AKI independent of eGFR.

Conclusions and Relevance

Proteinuria was associated with postoperative AKI and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management.

The NICE classification for 'Ultra-radical (extensive) surgery for advanced ovarian cancer' guidance does not meaningfully predict postoperative complications: a cohort study

OBJECTIVE

To determine which descriptors of cytoreductive surgical extent in advanced ovarian cancer (AOC) best predict postoperative morbidity.

DESIGN

Retrospective notes review.

SETTING

A gynaecological cancer centre in the UK.

POPULATION

Six hundred and eight women operated on for AOC over a period of 114 months at a tertiary cancer centre, between 16 August 2007 and 16 February 2017.

METHODS

Outcome data were analysed by six approaches to classify the extent of surgery: standard/ultra-radical surgery; standard/radical/supra-radical surgery; presence/absence of gastrointestinal resections; low/intermediate/high surgical complexity score (SCS); presence of bowel anastomoses and/or diaphragmatic surgery; and the presence/absence of multiple bowel resections.

MAIN OUTCOME MEASURES

Major (grades 3-5) postoperative morbidity and mortality.

RESULTS

Forty-three (7.1%) patients experienced major complications. Grade-5 complications occurred in six patients (1.0%). Patients who underwent multiple bowel resections had a relative risk (RR) of 7.73 (95% confidence interval, 95% CI 3.92-15.26), patients with a high SCS had an RR of 6.12 (95% CI 3.25-11.52), patients with diaphragmatic surgery and gastrointestinal anastomosis had an RR of 5.57 (95% CI 2.65-11.72), patients with 'any gastrointestinal resection' had an RR of 4.69 (95% CI 2.66-8.24), patients with ultra-radical surgery had an RR of 4.65 (95% CI 2.26-8.79), and patients with supra-radical surgery had an RR of 4.20 (95% CI 2.35-7.51) of grades 3-5 morbidity, compared with patients undergoing standard surgery as defined by the National Institute for Health and Care Excellence (NICE) in the UK. No significant difference was seen in the rate of major morbidity between standard (6/59, 10.2%) and ultra-radical (9/81, 11.1%) surgery within the cohort who had intermediate complex surgery (P > 0.05).

CONCLUSIONS

The numbers of procedures performed significantly correlate with major morbidity. The number of procedures performed better predicted major postoperative morbidity than the performance of certain 'high risk' procedures. We recommend using SCS to define a higher risk operation. NICE should re-evaluate the use of the term 'ultra-radical' surgery.

TWEETABLE ABSTRACT

Multiple bowel resection is the best predictor of morbidity and is more predictive than 'ultra-radical surgery'.

Reporting of complications after laparoscopic cholecystectomy: a systematic review

BACKGROUND

Consistent measurement and reporting of outcomes, including adequately defined complications, is important for the evaluation of surgical care and the appraisal of new surgical techniques. The range of complications reported after LC has not been evaluated. This study aimed to identify the range of complications currently reported for laparoscopic cholecystectomy (LC), and the adequacy of their definitions.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting clinical outcomes of LC, between 2013 and 2016.

RESULTS

In total 233 studies were included, reporting 967 complications, of which 204 (21%) were defined. One hundred and twenty-two studies (52%) did not provide definitions for any of the complications reported. Conversion to open cholecystectomy was the most commonly reported complication, reported in 135 (58%) studies, followed by bile leak in 89 (38%) and bile duct injury in 75 (32%). Mortality was reported in 89 studies (38%).

CONCLUSION

Considerable variation was identified between studies in the choice of measures used to evaluate the complications of LC, and in their definitions. A standardised set of core outcomes of LC should be developed for use in clinical trials and in evaluating the performance of surgical units.

Predictors of Unplanned Reoperation for Ovarian Cancer Patients From the National Surgical Quality Improvement Program Database

OBJECTIVES

The aim of this study was to determine preoperative risk factors associated with unplanned reoperation within 30 days for patients undergoing major surgery for primary ovarian cancer using the National Surgical Quality Improvement Program database.

METHODS

We conducted a retrospective cohort study utilizing the National Surgical Quality Improvement Program database to identify patients undergoing primary ovarian cancer surgery from 2012 to 2014. Patients who had a reoperation within 30 days of their primary surgery were identified. Demographics and clinical covariates were calculated. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using univariate and multivariate logistic regression approaches to assess the association.

RESULTS

A total of 4260 patients were identified during the study period. One hundred forty-eight patients (3.5%) underwent a reoperation within 30 days of their primary surgery. In univariate analysis, preoperative creatinine 1.5 mg/dL or greater (P = 0.010), smoking (P = 0.003), and both insulin-dependent (P = 0.029) and non-insulin-dependent diabetes mellitus (P = 0.048) were predictive of a reoperation. Multivariate analysis noted that smoking (OR, 1.94; 95% CI, 1.26-2.99), insulin-dependent diabetes mellitus (OR, 2.18; 95% CI, 1.08-4.40), non-insulin-dependent diabetes mellitus (OR, 1.65; 95% CI, 1.01-2.72), and preoperative creatinine (OR, 2.65; 95% CI, 1.26-5.58) were predictive of a reoperation. Age 50 to 60 years was protective against reoperation when compared with age younger than 50 years (OR, 0.54; 95% CI, 0.32-0.90).

CONCLUSIONS

Efforts to reduce reoperation rates should focus on identifying high-risk patients by utilizing objective preoperative data. Optimizing their medical status prior to surgery may decrease the reoperation rate in patients with ovarian cancer, thereby improving outcomes and providing a probable cost benefit.

Risk of Stroke After Colorectal Surgery for Cancerous Versus Benign Conditions

BACKGROUND

Cancer treatment, specifically surgical intervention, as a possible stroke trigger is understudied.

METHODS

Using the Nationwide Readmissions Database and validated diagnosis and procedure codes, we identified adults with index admissions for colorectal surgery for colorectal adenocarcinoma (Group A) and compared them to admissions for colorectal surgery for benign conditions (Group B) and hepatobiliary or pancreatic surgery for benign conditions (Group C). Within the colorectal cancer cohort, we further identified patients who underwent open versus laparoscopic surgery. The primary outcome was readmission for ischemic or hemorrhagic stroke up to 1 year. Cumulative risk of ischemic stroke was calculated using risk survival statistics, and hazard ratios (HR) were calculated using adjusted Cox regression.

RESULTS

Patients in Group A had higher 3-month readmission rates for ischemic and hemorrhagic strokes than those in Groups B and C. Higher risk of ischemic stroke (HR 1.46, 95% confidence interval [CI] 1.20-1.79) in Group A compared to Group B was eliminated following adjustments for illness severity and vascular risk factors. Comparing types of colorectal surgical intervention for cancer, there was significantly greater risk of ischemic stroke with open versus laparoscopic surgery, despite adjusting for vascular risk factors (HR 1.70, 95% CI 1.15-2.52).

CONCLUSIONS

We found elevated risk of ischemic stroke up to 1 year following open surgery for colorectal adenocarcinoma compared to laparoscopic. More research is necessary to clarify the underlying surgery-related mechanisms that contribute to elevated risk.

Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration

OBJECTIVE

Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers.

DATA SOURCES

Veterans Health Administration's Corporate Data Warehouse.

STUDY DESIGN

Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE.

PRINCIPAL FINDINGS

Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent.

CONCLUSIONS

The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE.

Prognostic Role of High-sensitivity Cardiac Troponin I and Soluble Suppression of Tumorigenicity-2 in Surgical Intensive Care Unit Patients Undergoing Non-cardiac Surgery

Background

The prognostic utility of cardiac biomarkers, high-sensitivity cardiac troponin I (hs-cTnI) and soluble suppression of tumorigenicity-2 (sST2), in non-cardiac surgery is not well-defined. We evaluated hs-cTnI and sST2 as predictors of 30-day major adverse cardiac events (MACE) in patients admitted to the surgical intensive care unit (SICU) following major non-cardiac surgery.

Methods

hs-cTnI and sST2 concentrations were measured in 175 SICU patients immediately following surgery and for three days postoperatively. The results were analyzed in relation to 30-day MACE and were compared with the revised Goldman cardiac risk index (RCRI) score.

Results

Overall, 30-day MACE was observed in 16 (9.1%) patients. hs-cTnI and sST2 concentrations differed significantly between the two groups with and without 30-day MACE (P<0.05). The maximum concentration of sST2 was an independent predictor of 30-day MACE (odds ratio=1.016, P=0.008). The optimal cut-off values of hs-cTnI and sST2 for predicting 30-day MACE were 53.0 ng/L and 182.5 ng/mL, respectively. A combination of hs-cTnI and sST2 predicted 30-day MACE better than the RCRI score. Moreover, 30-day MACE was observed more frequently with increasing numbers of above-optimal cut-off hs-cTnI and sST2 values (P<0.0001). Reclassification analyses indicated that the addition of biomarkers to RCRI scores improved the prediction of 30-day MACE.

Conclusions

This study demonstrates the utility of hs-cTnI and sST2 in predicting 30-day MACE following non-cardiac surgery. Cardiac biomarkers would provide enhanced risk stratification in addition to clinical RCRI scores for patients undergoing major non-cardiac surgery.

Factors Associated with Short-Term Morbidity in Patients Undergoing Colon Resection for Crohn's Disease

BACKGROUND

Patients undergoing colon resection for Crohn's disease are at risk of developing postoperative complications. The aim of this study is to identify factors associated with short-term (30-day) morbidity in patients undergoing colon resection for Crohn's disease from a national database.

METHODS

Patients who underwent colon resection for Crohn's disease in 2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The groups were classified based on presence of postoperative 30-day complications. The overall morbidity was calculated by including patients who had at least one postoperative complication. Demographics, preoperative, and operative factors were assessed and compared between the two groups. Further multivariate logistic regression analysis was conducted.

RESULTS

A total of 1643 patients met the inclusion criteria [mean age of 41.2 (± 15.5) years, 871 (53%) female]. Sixty percent (n = 993) of the procedures were performed laparoscopically and 128 (12.8%) cases were converted to open. Ninety-five patients (5%) underwent emergent resections. Thirty percent (n = 507) of patients had at least one postoperative complication within 30 days of surgery. Ileus (16%), transfusion (7%), and organ-space surgical site infection (6%) were the most common morbidities. Independent risk factors for postoperative morbidity were male gender (p = 0.01), open surgery (p = 0.002), preoperative severe anemia (p = 0.001), and preoperative weight loss (p = 0.04).

CONCLUSION

Approximately one third of the patients who undergo colon resection for Crohn's disease experience postoperative complications. Preoperative optimization of nutrition and anemia may improve outcomes. Laparoscopic technique appears to be the preferred surgical treatment option for resection when feasible.

How Fast Should a Total Knee Arthroplasty Be Performed? An Analysis of 140,199 Surgeries

BACKGROUND

Although previous studies have shown that prolonged operative times can lead to an increased risk of complications after total knee arthroplasty (TKA), they only evaluated a few complications. It is also unclear whether a distinctive operative time exists after which complications increase. Therefore, this study was performed to (1) assess whether higher operative time increases the risk of complications within 30 days of TKA and (2) explore the relationship between operative time and various complications to identify possible operative times where complication rates increase.

METHODS

The National Surgical Quality Improvement Project database was queried from 2011 to 2015 to identify 140,199 primary TKAs. The effect of operative time (skin-to-skin) on various medical and surgical complications within 30 days was evaluated using multivariable logistic regression models. Spline regression models were created to further study the relationship between operative time and complications.

RESULTS

After adjusting for confounding factors, longer operative times were associated with higher risks of readmission (P < .001), reoperation (P < .001), surgical site infection (P < .001), wound dehiscence (P < .001), and transfusion (P < .001). The majority of the complications demonstrated an increase throughout the range of operative time, with a slightly pronounced increase in the risk of complications when the operative time was longer than 80 minutes.

CONCLUSION

Prolonged operative times were associated with an increased risk of a number of important complications such as readmissions, reoperations, surgical site infections, and wound complications. Based on our results, an operative time goal of less than 80 minutes is helpful for minimizing these complications after TKA.

Delayed Ileal Pouch Anal Anastomosis Has a Lower 30-Day Adverse Event Rate: Analysis From the National Surgical Quality Improvement Program

BACKGROUND

Ulcerative colitis (UC) patients requiring colectomy often have a staged ileal pouch anal anastomosis (IPAA). There are no prospective data comparing timing of pouch creation. We aimed to compare 30-day adverse event rates for pouch creation at the time of colectomy (PTC) with delayed pouch creation (DPC).

METHODS

Using prospectively collected data from 2011-2015 through the National Surgical Quality Improvement Program, we conducted a cohort study including subjects aged ≥18 years with a postoperative diagnosis of UC. We assessed 30-day postoperative rates of unplanned readmissions, reoperations, and major and minor adverse events (AEs), comparing the stage of the surgery where the pouch creation took place. Using a modified Poisson regression model, we estimated risk ratios (RRs) with 95% confidence intervals (CIs) adjusting for age, sex, race, body mass index, smoking status, diabetes, albumin, and comorbidities.

RESULTS

Of 2390 IPAA procedures, 1571 were PTC and 819 were DPC. In the PTC group, 51% were on chronic immunosuppression preoperatively, compared with 15% in the DPC group (P < 0.01). After controlling for confounders, patients who had DPC were significantly less likely to have unplanned reoperations (RR, 0.42; 95% CI, 0.24-0.75), major AEs (RR, 0.72; 95% CI, 0.52-0.99), and minor AEs (RR, 0.48; 95% CI, 0.32-0.73) than PTC.

CONCLUSIONS

Patients undergoing delayed pouch creation were at lower risk for unplanned reoperations and major and minor adverse events compared with patients undergoing pouch creation at the time of colectomy. 10.1093/ibd/izy082_video1izy082.video15776112442001.

The Relationship Between Age and Chronic Kidney Disease in Patients Undergoing Pancreatic Resection

BACKGROUND

Severe chronic kidney disease (CKD) predicts adverse outcomes in patients undergoing pancreatectomy, but the impact of milder CKD is unknown. Additionally, some authors have suggested that, due to physiologic changes of aging, CKD is over-diagnosed in patients above age 65.

METHODS

Patients undergoing pancreatectomy for malignancy from 2005 to 2014 were identified from the National Surgical Quality Improvement Program. Primary outcomes were all-cause mortality and major complication, defined as myocardial infarction, cardiac arrest, stroke, venous thromboembolism, respiratory failure, deep surgical site infection, pneumonia, acute kidney injury, coma > 24 h, or re-operation occurring within 30 days of surgery.

RESULTS

The mean age of 16,173 participants was 66 (range 18-90). Median preoperative creatinine was 0.80 mg/dL (0.10-11.0), and median preoperative eGFR was 86.36 mL/min/1.73m² (2.98-182.2). Mortality and major complication occurred in 3 and 23% of patients, respectively. In adjusted analyses, CKD stages 2 (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 1.10-1.40), 3a (aOR 1.50, 95% CI 1.24-1.82), 3b (aOR 1.56, 95% CI 1.19-2.06), and 4 (aOR 2.17, 95% CI 1.25-3.76) were associated with increased major complication, and CKD stage 4 was associated with increased mortality (aOR 2.68, 95% CI 1.10-6.56). Age did not influence the relationship between CKD and either outcome.

CONCLUSION

CKD of any stage was associated with an increased risk of postoperative major complication, and severe CKD was associated with increased mortality among patients undergoing pancreatectomy for malignancy. These associations were not diminished in elderly patients. Our findings could inform preoperative counseling and decision-making.

No Difference in Major Complication and Readmission Rates Following Simultaneous Bilateral vs Unilateral Total Hip Arthroplasty

BACKGROUND

Simultaneous bilateral total hip arthroplasty (THA) is an attractive option for patients with osteoarthritis as it requires a single anesthetic and hospitalization. Nonetheless, serious concerns remain over the perioperative safety and rate of hospital readmission. The purpose of the present study was to compare the rate of 30-day major complications and hospital readmissions between patients undergoing simultaneous bilateral vs unilateral THA using the National Surgical Quality Improvement Program database.

METHODS

The National Surgical Quality Improvement Program database was queried from 2011 to 2015 inclusively to identify all cases of elective, primary simultaneous bilateral THA and match them to a control group of unilateral THA cases. A multivariable regression analysis was then used to assess the relationship of simultaneous bilateral vs unilateral THA on major complications and readmissions.

RESULTS

A total of 575 bilateral THA patients were matched to 2290 unilateral THA patients using a 4:1 ratio based on age, sex, and American Society of Anesthesiologists scores. Bilateral THA patients were more likely to undergo general anesthesia (77% vs 58.7%, P < .0001), required more postoperative transfusions (29.2% vs 15.9%, P < .0001) and were more often discharged to a rehabilitation facility rather than home (39.4% vs 20.8%, P < .0001). However, the adjusted odds of a major complication (odds ratio = 0.72, 95% confidence interval [0.41-1.24], P = .24) and 30-day readmission (odds ratio = 0.67, 95% confidence interval [0.38-1.19], P = .17) were similar between the 2 groups.

CONCLUSION

Although patients who underwent simultaneous bilateral THA were more likely to be discharged to a rehabilitation facility and required significantly more perioperative transfusions compared to those undergoing unilateral THA, the odds of a 30-day major complication and readmission were similar between groups.

LEVEL OF EVIDENCE

III.

Autonomous detection, grading, and reporting of postoperative complications using natural language processing

INTRODUCTION

Natural language processing, a computer science technique that allows interpretation of narrative text, is infrequently used to identify surgical complications. We designed a natural language processing algorithm to identify and grade the severity of deep venous thrombosis and pulmonary embolism (together: venous thromboembolism).

METHODS

Patients from our 2011-2014 American College of Surgeons National Surgical Quality Improvement Project cohorts with a duplex ultrasound or a computerized tomography angiography of the chest performed within 30 days of surgery were divided into training and validation datasets. A "bag of words" approach classified the reports; other electronic health record data classified the venous thromboembolism's severity.

RESULTS

Of the 10,295 American College of Surgeons National Surgical Quality Improvement Project patients, 251 were used in our deep venous thromboses validation cohort (273 total ultrasounds) and 506 in our pulmonary embolisms cohort (552 total computerized tomography angiographies). For deep venous thromboses the sensitivity and specificity were 85.1% and 94.6%, while for pulmonary embolisms they were 90% and 98.7%. Most discordances were due to lack of imaging documentation of a deep venous thrombosis (28/41, 68.3%) or pulmonary embolism (6/6, 100%). Most deep venous thromboses (28 patients, 54.6%) and pulmonary embolisms (25 patients, 75.8%) required administration of therapeutic intravenous or subcutaneous anticoagulation.

CONCLUSION

Natural language processing can reliably detect the presence of postoperative venous thromboembolisms, and its use should be expanded for the detection of other conditions from narrative documentation.

Experiences with the standardized classification of surgical complications (Clavien-Dindo) in general surgery patients

Background

The standardized Clavien-Dindo classification of surgical complications is applied as a simple and widely used tool to assess and report postoperative complications in general surgery. However, most documentation uses this classification to report surgery-related morbidity and mortality in a single field of surgery or even particular intervention. The aim of the present study was to present experiences with the Clavien-Dindo classification when applied to all patients on the general surgery ward of a tertiary referral care center.

Methods

We analyzed a period of 6 months of care on a ward with a broad range of general and visceral surgery. Discharge reports and patient charts were analyzed retrospectively and reported complications rated according to the most recent Clavien-Dindo classification version. The complexity of operations was assessed with the Austrian Chamber of Physicians accounting system.

Results

The study included 517 patients with 817 admissions, of whom 463 had been operated upon. Complications emerged in 12.5%, of which 19% were rated as Clavien I, 20.7% as Clavien II, 13.8% as Clavien IIIa, 27.6% as Clavien IIIb, 8.6% as Clavien IVa, and 10.3% as Clavien V. No Clavien grade IVb complication occurred within the investigation. Patients having undergone more complex surgery or with higher scores experienced significantly longer lengths of hospital stay.

Conclusion

The Clavien-Dindo classification can easily be used to document complication rates in general surgery, even though this collective was not included in the original validation studies of Clavien et al. and consisted of more heavily impaired patients.

Utilizing Big Data in Cancer Care

Clinical research has boomed over the past decade, with the development of multiple clinical datasets that are available for retrospective review. However, data remain incomplete based on fragmented reporting, provider change, and loss of follow-up. New technologies are being developed to assist with this limitation, by joining health care systems' medical records, and tracking Medicare claims files. The future of health care will rely more heavily on these systems, and artificial intelligence to quickly pull relevant clinical and genomic data regarding particular diagnoses, as a means to personalize medicine. This article reviews current advances in management of Big Data.

Surgical Collaboratives for Quality Improvement

How best to improve the surgical quality remains unknown. Historically, most efforts were either top down national policy efforts or local hospital/practice level efforts. This article reviews the limitations of these methods and how collaborative quality improvement a mix of local, regional, and national efforts is the most effective means of achieving sustainable, meaningful improvement in surgical care.

Long-term Trends in Head and Neck Surgery Outcomes

OBJECTIVE

The aim of the present study is to address the paucity of data on long-term trends in postoperative complication rates in head and neck surgery. Specifically, this study assesses trends in morbidity and mortality following head and neck surgery over a 20-year period from 1995 to 2015 and identifies risk factors for the development of complications.

STUDY DESIGN

Retrospective cross-sectional analysis of Veterans Affairs Surgical Quality Improvement Program database from 1995 to 2015.

SETTING

Veterans Affairs medical centers across the United States.

SUBJECTS AND METHODS

Using the Veterans Affairs Surgical Quality Improvement Program database, we selected 44,161 patients undergoing head and neck procedures from 1995 to 2015. Trends in 30-day morbidity and mortality were assessed, and univariate and multivariate analyses of risk factors for complications were performed.

RESULTS

From 1995-2000 to 2011-2015, overall complication rates decreased >45% (from 10.9% to 5.9%), and 30-day postsurgical mortality decreased nearly 70% (from 1.3% to 0.4%). Postoperative hospital stays also significantly declined. Major procedures, such as free flap cases and total laryngectomies, had less change in complication rate as compared with less invasive procedures.

CONCLUSION

Substantial improvement in postoperative morbidity and mortality has taken place in head and neck surgery over the past decades. Static complication rates in some procedures may reflect that the improvement of surgical techniques allow for the treatment of sicker patients. The trends seen in this study speak to the importance of probing further why high rates of complications are still seen in certain procedures and ensuring that effective treatment is balanced with limiting morbidity and mortality.

Unplanned reoperation after hepatectomy: an analysis of risk factors and outcomes

BACKGROUND/PURPOSE

Reoperation is being increasingly utilized as a metric for surgical care quality. The aim of this study was to identify the incidence of and risk factors for unplanned reoperation following index hepatectomy.

METHODS

Pre, intra- and post-operative information of patients who underwent partial hepatectomy in 435 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2013 were analyzed.

RESULTS

343 (4%) of 9195 patients required reoperation within 30 days of index hepatectomy. The index procedures with the highest incidence of reoperation (%) were trisectionectomy (7%) and right hepatectomy (5%). Patients who underwent reoperation had increased index operative duration (323 ± 174 min versus 243 ± 125 min, p < 0.001), postoperative transfusion (57% versus 23%, p < 0.001), wound complications, cardiorespiratory, renal, thromboembolic, and infectious events. Hemorrhage was the most common indication for reoperation (10%). Male gender, ASA class 4, and right hepatectomy or trisectionectomy were independent predictors of reoperation (OR 1.4 [1.1-1.7], p = 0.007; 2.0 [1.3-3.1], p = 0.003; 1.6 [1.2-2.0], p = 0.001 and 2.5 [1.8-3.4], p < 0.001, respectively). All reoperations occurred during index hospitalization and resulted in longer mean length of stay (19 ± 17 days versus 7 ± 7 days, p < 0.001).

CONCLUSION

Reoperation is associated with several patient characteristics and procedural factors in this national sample. Knowledge of these factors can increase awareness of patients at risk for reoperation.

Self-reported mobility as a preoperative risk assessment tool in older surgical patients compared to the American College of Surgeons National Surgical Quality Improvement Program

Background

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP®) developed a surgical risk calculator using data from 1.4 million patients and including 1557 unique Current Procedural Terminology (CPT) codes. Although this calculator demonstrated excellent performance in predicting postoperative mortality, morbidity, and six surgical complications, it was not developed specifically for use in older surgical patients who have worse surgical outcomes and additional unique risk factors compared to younger adults. We aimed to test the ability of a simple self-reported mobility tool to predict postoperative outcomes in the older surgical population compared to the NSQIP.

Methods

We used data from a prospective cohort study that enrolled 197 older surgical patients (≥ 69 years) undergoing various elective surgeries and assessed 30-day surgical outcomes. Statistical models included data from the Mobility Assessment Tool-short form (MAT-sf) alone, covariates alone, and MAT-sf data and covariates. We used leave-one-out (LOO) cross-validation of the models within our cohort and compared their performance for predicting postoperative outcomes against the NSQIP calculator based on receiver operating characteristic area under the curve (ROC AUC).

Results

Patients with poor self-reported mobility experienced higher rates of postoperative complications and nursing home placement. There was no difference in performance between any of our models and the NSQIP calculator (p > 0.1), with AUC between 0.604 and 0.697 for predicting postoperative complications and 0.653 and 0.760 for predicting nursing home placement. All models also predicted a length of stay (LOS) similar to the actual LOS.

Conclusion

Mobility assessment alone using MAT-sf can predict postoperative complications, nursing home placement, and LOS for older surgical patients, with accuracy comparable to that of the NSQIP calculator. The simplicity of this noninvasive risk assessment tool makes it an attractive alternative to the NSQIP calculator that requires 20 patient predictors and the planned procedure, or CPT code to predict the chance that patients will have 15 different adverse outcomes following surgery.

Revised cardiac risk index poorly predicts cardiovascular complications after adhesiolysis for small bowel obstruction

BACKGROUND

The number of patients undergoing preoperative risk stratification in the United States is expected to increase as the population ages. A large percentage of patients undergo some form of preoperative testing, and society guidelines suggest that up to 50% of the testing in lower risk surgical subgroups is unnecessary. The Revised Cardiac Risk Index and the risk calculator of the American College of Surgeons National Surgical Quality Improvement Program are widely used tools as the first step of preoperative cardiac evaluation. The Revised Cardiac Risk Index was developed to fill a need for objective perioperative cardiac risk evaluation. Despite the ease of use of Revised Cardiac Risk Index, it is uncertain if the stratification is accurate for surgical patients because its accuracy in large surgical samples has not been tested. With the National Surgical Quality Improvement Program risk calculator having excellent accuracy in estimating cardiac complications (area under the receiver operating characteristic 0.895), a unique opportunity to test the predictive accuracy of postsurgical cardiac events became available. The purpose of this study is to determine the accuracy of the Revised Cardiac Risk Index for predicting cardiovascular complications after adhesiolysis for small bowel obstruction.

METHODS

From 2005 to 2015, 34,032 cases of open or laparoscopic adhesiolysis (Current Procedural Terminology codes 44005 and 44180) for small bowel obstruction (International Classification of Diseases, 10th edition [ICD-10]) were analyzed using the National Surgical Quality Improvement Program dataset. Revised Cardiac Risk Index estimates were calculated for each case and compared to reported cardiovascular complications (myocardial infarction or cardiac arrest) using univariable logistic regression. Overall predictive accuracy was assessed by measuring model discrimination (area under the receiver operating characteristic) and model calibration (Hosmer-Lemeshow chi-squared statistics).

RESULTS

Although the Revised Cardiac Risk Index predicted cardiovascular complications with an odds ratio of 2.3 and a 95% confidence interval of 1.9 to 2.8 (P < .001) and the Hosmer-Lemeshow chi-square was significant (0.22, P = 0.64), the area under the receiver operating characteristic was poor (0.63, 95% confidence interval 0.59-0.67).

CONCLUSION

Despite its relative simplicity, the Revised Cardiac Risk Index performed poorly as a predictor of cardiovascular complications after adhesiolysis for small bowel obstruction. These findings question the utility of the Revised Cardiac Risk Index in this patient population. Future studies should aim to develop models that are computationally simple while retaining predictive accuracy.

Association between Obesity, Surgical Route, and Perioperative Outcomes in Patients with Uterine Cancer

Objective

To study temporal trends of hysterectomy routes performed for uterine cancer and their associations with body mass index (BMI) and perioperative morbidity.

Methods

A retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2013 databases was conducted. All patients who were 18 years old and older with a diagnosis of uterine cancer and underwent hysterectomy were identified using ICD-9-CM and CPT codes. Surgical route was classified into four groups: total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopic assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH) including both conventional and robotically assisted. Patients were then stratified according to BMI.

Results

7199 records were included in the study. TLH was the most commonly performed route of hysterectomy regardless of BMI, with proportions of 50.9%, 48.9%, 50.4%, and 51.2% in ideal, overweight, obese, and morbidly obese patients, respectively. The median operative time for TAH was 2.2 hours compared to 2.7 hours for TLH (p < 0.01). The median length of stay for TAH was 3 days compared to 1 day for TLH (p < 0.01). The percentage of patients with an adverse outcome (composite indicator including transfusion, deep venous thrombosis, and infection) was 17.1 versus 3.7 for TAH and TLH, respectively (p < 0.01).

Conclusion

During the last decade, TLH has been increasingly performed in women with uterine cancer. The increased adoption of TLH was seen in all BMI subgroups.

The Era of the Large Databases: Outcomes After Gastroesophageal Surgery According to NSQIP, NIS, and NCDB Databases. Systematic Literature Review

BACKGROUND

The term big data refers to databases that include large amounts of information used in various areas of knowledge. Currently, there are large databases that allow the evaluation of postoperative evolution, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), and the National Cancer Database (NCDB). The aim of this review was to evaluate the clinical impact of information obtained from these registries regarding gastroesophageal surgery.

METHODS

A systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines was performed. The research was carried out using the PubMed database identifying 251 articles. All outcomes related to gastroesophageal surgery were analyzed.

RESULTS

A total of 34 articles published between January 2007 and July 2017 were included, for a total of 345 697 patients. Studies were analyzed and divided according to the type of surgery and main theme in (1) esophageal surgery and (2) gastric surgery.

CONCLUSIONS

The information provided by these databases is an effective way to obtain levels of evidence not obtainable by conventional methods. Furthermore, this information is useful for the external validation of previous studies, to establish benchmarks that allow comparisons between centers and have a positive impact on the quality of care.

Individualized, perioperative, hemodynamic goal-directed therapy in major abdominal surgery (iPEGASUS trial): study protocol for a randomized controlled trial

Background

Postoperative morbidity and mortality in patients undergoing surgery is high, especially in patients who are at risk of complications and undergoing major surgery. We hypothesize that perioperative, algorithm-driven, hemodynamic therapy based on individualized fluid status and cardiac output optimization is able to reduce mortality and postoperative moderate and severe complications as a major determinant of the patients’ postoperative quality of life, as well as health care costs.

Methods/design

This is a multi-center, international, prospective, randomized trial in 380 patients undergoing major abdominal surgery including visceral, urological, and gynecological operations. Eligible patients will be randomly allocated to two treatment arms within the participating centers. Patients of the intervention group will be treated perioperatively following a specific hemodynamic therapy algorithm based on pulse-pressure variation (PPV) and individualized optimization of cardiac output assessed by pulse-contour analysis (ProAQT© device; Pulsion Medical Systems, Feldkirchen, Germany). Patients in the control group will be treated according to standard local care based on established basic hemodynamic treatment. The primary endpoint is a composite comprising the occurrence of moderate or severe postoperative complications or death within 28 days post surgery. Secondary endpoints are: (1) the number of moderate and severe postoperative complications in total, per patient and for each individual complication; (2) the occurrence of at least one of these complications on days 1, 3, 5, 7, and 28 in total and for every complication; (3) the days alive and free of mechanical ventilation, vasopressor therapy and renal replacement therapy, length of intensive care unit, and hospital stay at day 7 and day 28; and (4) mortality and quality of life, assessed by the EQ-5D-5L™ questionnaire, after 6 months.

Discussion

This is a large, international randomized controlled study evaluating the effect of perioperative, individualized, algorithm-driven ,hemodynamic optimization on postoperative morbidity and mortality.

Trial registration

Trial registration: NCT03021525. Registered on 12 January 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2620-9) contains supplementary material, which is available to authorized users.

Total shoulder arthroplasty in octogenarians: Is there a higher risk of adverse outcomes?

This study used the National Surgical Quality Improvement Program to evaluate octogenarians who underwent total shoulder arthroplasty (TSA). Specifically, we evaluated: (1) patient demographics; (2) perioperative factors; and (3) 30-day postoperative complications. Compared to controls, the octogenarians had more females, white patients, lower BMIs, fewer smokers, less functionally independent, higher ASA scores, shorter operative times, and longer LOS. Octogenarians had greater odds for developing any (OR = 2.05; 95%CI, 1.70-2.46), any major (OR = 2.28; 95%CI, 1.66-3.13), and any minor (OR = 1.99; 95%CI, 1.63-2.45) complications. Perioperative risk management strategies for elective TSA in the elderly may help mitigate the increased perioperative risks associated with age.

Morbidity and Mortality Risk Assessment in Gynecologic Oncology Surgery Using the American College of Surgeons National Surgical Quality Improvement Program Database

INTRODUCTION

Gynecologic oncology patients represent a distinct patient population with a variety of surgical risks. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database provides an opportunity to analyze large cohorts of patients over extended periods with high accuracy. Our goal was to develop a postoperative risk assessment calculator capable of providing a standardized, objective means of preoperatively identifying high-risk patients in the gynecologic oncology population.

METHODS

We queried the ACS NSQIP database for gynecologic oncology patients from 2005 to 2013. Multivariate logistic regression was performed to generate predictive models specific for 30-day postoperative mortality and major morbidity.

RESULTS

There were 12,831 patients with a primary gynecologic malignancy identified: 7847 uterine, 3366 adnexal, 1051 cervical, and 567 perineum cancers. In this cohort, 125 (0.97%) patients died, and 784 (6.11%) major morbidity events were recorded within 30 days of their surgery. For 30-day mortality, the mean calculated predictive probability was 0.128 (SD, 0.219) compared with 0.009 (SD, 0.027) in patients alive 30 days postoperatively (P < 0.0001). The mean predictive probability of major morbidity was 0.097 (SD, 0.095) compared with 0.059 (SD, 0.043) in patients who did not experience major morbidity 30 days postoperatively (P < 0.0001).

CONCLUSIONS

Using NSQIP data, these predictive models will help to determine patients at risk for 30-day mortality and major morbidity. Further clinical validation of these models is required.

What Is the Relationship between Operative Time and Adverse Events after Colon and Rectal Surgery?

We propose that prolonged colorectal surgery operative times are associated with increased 30-day adverse events. We identified a cohort from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 2005 through December 2012. Patients who underwent colectomy with primary anastomosis were selected using CPT codes. Operative time was categorized into short, average, and long based on mean operative times 61 SD. NSQIP-approved multivariate models were used to identify associations between operative time and 30-day adverse events. A total of 113,615 patients underwent colorectal resection of which 46 per cent were laparoscopic and 12 per cent were identified as long operative times. Patients with long operative procedures had 34 per cent more superficial surgical site infections, 65 per cent more organ space infections, 69 per cent more abdominal dehiscences, 44 per cent more thrombotic complications, 45 per cent more urinary tract infections, 40 per cent more returns to the operating room, and 36 per cent more prolonged lengths of stay ( P < 0.05 for all analyses). The multivariable analysis revealed an association between long operative times and increased adverse events despite adjustment for all NSQIP recommended covariates. Our results reveal increased 30-day adverse events with increased operative time. We propose that operative time may serve as a proxy for surgical complexity in colorectal surgery.

Prediction Models for 30-Day Mortality and Complications After Total Knee and Hip Arthroplasties for Veteran Health Administration Patients With Osteoarthritis

BACKGROUND

Statistical models to preoperatively predict patients' risk of death and major complications after total joint arthroplasty (TJA) could improve the quality of preoperative management and informed consent. Although risk models for TJA exist, they have limitations including poor transparency and/or unknown or poor performance. Thus, it is currently impossible to know how well currently available models predict short-term complications after TJA, or if newly developed models are more accurate. We sought to develop and conduct cross-validation of predictive risk models, and report details and performance metrics as benchmarks.

METHODS

Over 90 preoperative variables were used as candidate predictors of death and major complications within 30 days for Veterans Health Administration patients with osteoarthritis who underwent TJA. Data were split into 3 samples-for selection of model tuning parameters, model development, and cross-validation. C-indexes (discrimination) and calibration plots were produced.

RESULTS

A total of 70,569 patients diagnosed with osteoarthritis who received primary TJA were included. C-statistics and bootstrapped confidence intervals for the cross-validation of the boosted regression models were highest for cardiac complications (0.75; 0.71-0.79) and 30-day mortality (0.73; 0.66-0.79) and lowest for deep vein thrombosis (0.59; 0.55-0.64) and return to the operating room (0.60; 0.57-0.63).

CONCLUSIONS

Moderately accurate predictive models of 30-day mortality and cardiac complications after TJA in Veterans Health Administration patients were developed and internally cross-validated. By reporting model coefficients and performance metrics, other model developers can test these models on new samples and have a procedure and indication-specific benchmark to surpass.

Risk assessment of morbidities after right hemicolectomy based on the National Clinical Database in Japan

OBJECTIVE

Nationwide databases are expected to provide critical data to improve medical practice. The present study used such data to develop risk models for clinically important outcomes after right hemicolectomy based on preoperative risk factors.

METHODS

Japan's National Clinical Database (NCD) identified 38 030 cases of right hemicolectomy in the years 2011 and 2012. These were used to analyze correlations between mortality and eight selected clinical outcomes of interest by Pearson's correlation coefficient (r). To construct risk models for the eight selected clinical outcomes, 80% of all the examined cases were extracted randomly as a development cohort, and preoperative risk factors for each clinical outcome were identified using a forward stepwise selection method. Morbidities predicted from the risk models were used to find areas under the receiver operator curves among the remaining 20% of the testing cohort.

RESULTS

The following clinical outcomes were identified as highly associated with operative mortality: systemic sepsis (r = .360), renal failure (r = .341), unplanned intubation (r = .316) and central nervous system (CNS) occurrences (r = .301). Risk models containing up to 21 preoperative variables were constructed for these eight postoperative clinical outcomes. Predictive values of the eight models were as follows: surgical site infections (0.634), anastomotic leakage (0.656), systemic sepsis (0.816), pneumonia (0.846), unplanned intubation (0.838), renal failure (0.883), CNS occurrences (0.833) and transfusion >5 units (0.846).

CONCLUSIONS

This study indicated that the NCD-generated risk models for six of the eight selected critical postoperative outcomes had high discrimination among right hemicolectomy patients. These risk models can accurately identify high-risk patients prior to surgery.

Application of HARM Score to Measure Surgical Quality and Outcomes in Bariatric Patients

BACKGROUND

The HospitAl stay, Readmission, and Mortality rates (HARM) score is a quality indicator that is easily determined from routine administrative data. However, the HARM score has not yet been applied to patients undergoing bariatric surgery.

OBJECTIVE

The aims of the present study were to adjust the HARM score to the bariatric population and to validate the ability of the modified HARM score to serve as an inexpensive tool to measure the quality of bariatric surgery.

METHODS

A MBSAQIP 2015 PUF database was reviewed. For each discharge, a 1 to 10 score was calculated on the basis of length of stay (LOS), discharge status, and 30-day readmissions. We adjusted the LOS categories to the distribution of LOS in the MBSQIP database. The new LOS categories were used to calculate the modified HARM score, referred to as the BARiatric HARM (BAR-HARM) score. The association between HARM and BAR-HARM scores and complication rate was assessed.

RESULTS

A total of 197,141 cases were evaluated: 98.8% were elective and 1.2% were emergent admissions. The mean individual patient BAR-HARM score was 1.75 ± 1.04 for elective cases, and 2.02 ± 1.45 for emergency cases. The complication rates for the respective BAR-HARM categories ≤ 2, > 2 to 3, > 3 to 4, and > 4 were 3.95, 27.53, 40.14, and 79.97% (p < 0.001).

CONCLUSIONS

The quality of bariatric surgery can be reliably and validly assessed using the BAR-HARM score, which is a modification of the HARM score.

Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients

BACKGROUND

Informed surgical consent requires accurate estimation of risks and benefits. Multiple risk assessment tools are available; however, most are not widely used or are specific to certain interventions. Assessing surgical risk is especially challenging in elderly patients because of their range of comorbidities, level of frailty, or severity of illness and a number of available surgical interventions.

DATA SOURCES

We searched MEDLINE from January 2014 to July 2017 for studies that used risk assessment tools in studies on elderly surgical patients. We then sought the original articles describing each assessment tool and subsequent validation studies.

CONCLUSIONS

We identified risk assessment tools that can improve surgical risk assessment in elderly surgical patients. The majority of the identified tools are not commonly used for pre-operative risk assessment. NSQIP-PMP, mFI and SURPAS are promising tools. Age is commonly used to predict risk, but frailty may be a more appropriate measure.